Feasibility and Diagnostic Validity of the M-3 Checklist: A Brief, Self-Rated Screen for Depressive, Bipolar, Anxiety, and Post-Traumatic Stress Disorders in Primary Care

Bradley N. Gaynes; Joanne DeVeaugh-Geiss; Sam Weir; Hongbin Gu; Cora MacPherson; Herbert C. Schulberg; Larry Culpepper; David R. Rubinow

doi:10.1370/afm.1092

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Progress in effective screening tool deserves documenting the availability of effective services
Sharon M McDonnell

Published on: 09 November 2010
Electronic scoring
catherine shisslak, Ph.D.

Published on: 21 April 2010
New instrument development
Stephen J Zyzanski

Published on: 09 April 2010
Brief, but can we make it fit?
Daniel C. Vinson

Published on: 28 March 2010

Published on: (9 November 2010)
Page navigation anchor for Progress in effective screening tool deserves documenting the availability of effective services
Progress in effective screening tool deserves documenting the availability of effective services
Sharon M McDonnell, Peacham, VT, USA
To the editors: Regarding.... Bradley N. Gaynes, Joanne DeVeaugh-Geiss, et al Feasibility and Diagnostic Validity of the M-3 Checklist: A Brief, Self- Rated Screen for Depressive, Bipolar, Anxiety, and Post-Traumatic Stress Disorders in Primary Care Ann Fam Med 2010; 8: 160-169
I commend the authors— This is an important topic with good research providing a useful tool in the context of real patient care. If only mo...
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To the editors: Regarding.... Bradley N. Gaynes, Joanne DeVeaugh-Geiss, et al Feasibility and Diagnostic Validity of the M-3 Checklist: A Brief, Self- Rated Screen for Depressive, Bipolar, Anxiety, and Post-Traumatic Stress Disorders in Primary Care Ann Fam Med 2010; 8: 160-169
I commend the authors— This is an important topic with good research providing a useful tool in the context of real patient care. If only more diagnostic and treatment modalities were as thoroughly studied and performed as well as this one appears to. The sensitivity and specificity of the screening test compares favorably with mammography for breast cancer and fecal occult blood testing for colon cancer. (1,2)
Now we need to understand and build the support systems available for primary care physicians and their patients with a positive screen using these tools. Many communities are so short on mental health and social services professionals or community-based care and follow-up programs that the effectiveness and utility of timely and valid diagnosis is fundamentally undermined.
I believe we need to expand our inquiry and document whether the services needed to treat these persons effectively are available. Does screening result in effective treatment? Effective therapy involves not just medications but interventions and treatment by other members of the health care team. Do our patients have a place to go and/or a regimen available to them if we make a referral? Insofar as we must attend to the signs of concern and make a judgment about significance and the need for treatment, I believe we need to assess the proportion of time services are actually available for care. The high prevalence of these disorders— robbing patients and families of vitality and resilience— not to mention the additional risk they add to co-morbid medical conditions, means that we should expect that supportive programs structures, and systems are available and accessible. Good medical practice demands it.
These support systems may vary in different communities, and may include outpatient or community based nursing, public health programs, social services, psychological therapies, biofeedback, and peer support. I am not advocating for a particular response but for us to document whether the diagnosis leads to the possibility of effective treatment— a treatment arm we can facilitate and orchestrate but most often cannot provide directly.
The ultimate test of the tool would be the extent to which it contributes to improved outcomes in the condition it helps detect. The gaps we know exist are often explained as patient non-compliance, but in my experience the gap is more likely the result of classic support services disappearing and newer programs such as PEARLS (A community based mental health treatment for depression particularly among elderly patients) and others like it that show good results, are not widely available.(3) With a screening tool this good we can begin to document— with data— services or the lack thereof, and then together (even just a few of us) advocate or demand for their availability as essential.
Respectfully, Sharon
Sharon McDonnell MD MPH
Associate Professor Dartmouth Medical School, Dept Family and Community Medicine and The Dartmouth Institute for Health Policy and Clinical Practice
Senior Consulting Epidemiologist, Centers for Disease Control and Prevention
Owner, Mother-Daugher Press and Gaybumgarner Images
References:
1. Gøtzsche PC, Nielsen M. Screening for breast cancer with mammography. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD001877. DOI: 10.1002/14651858.CD001877.pub2. Accessed November 6, 2010
2. Screening for Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. U.S. Preventive Services Task Force* Ann. Int Med Nov 4, 2008 vol. 149 no. 9 627-637
3. Program to Encourage Active, Rewarding Lives for Seniors (PEARLS)—A Depression Management Program for Elderly Adults. CDC Prevention Research Program: Effective interventions. http://www.cdc.gov/prc/prevention-strategies/effective-interventions/program-encourage-active-rewarding-lives-seniors-depression-management.htm. Accessed November 6, 2010.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (21 April 2010)
Page navigation anchor for Electronic scoring
Electronic scoring
catherine shisslak, Ph.D., tucson, AZ
We use electronic medical records and would like to incorporate the scoring of the M3 into this EMR. Any suggestions?
Thanks, Catherine
Competing interests: None declared

Competing Interests: None declared.
Published on: (9 April 2010)
Page navigation anchor for New instrument development
New instrument development
Stephen J Zyzanski, Cleveland, USA
The authors of this study are to be commended for their efforts in developing a new checklist tool (M-3) for diagnosing psychiatric disorders in primary care. Given the under recognition of these disorders in primary care practices, the authors make a strong case for a new measure. Many current measures either address one disorder or, at best, are narrowly focused. The items for this new tool were generated by experien...
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The authors of this study are to be commended for their efforts in developing a new checklist tool (M-3) for diagnosing psychiatric disorders in primary care. Given the under recognition of these disorders in primary care practices, the authors make a strong case for a new measure. Many current measures either address one disorder or, at best, are narrowly focused. The items for this new tool were generated by experienced clinicians in the field and were specifically intended for use in a primary care setting. Moreover, the authors conducted rigorous psychometric testing and evaluation of the new tool including concurrent validity and feasibility assessments. The M-3 checklist is attractive in that it is a 1-page screening tool that addresses four mood and anxiety disorders. It takes less than 5 minutes to complete and more than 80% of the clinicians said they were able to review the checklist in 30 or fewer seconds. In addition, more than 60% of patients reported that the M-3 helped them to talk to their doctors about their mood or feelings. This is a solid example of the type of instrument development that can benefit the future identification and treatment of patients with these disorders. A tool such as this one is more likely to be used because it provides assessments of multiple psychiatry disorders, is brief and easy to score, and thanks to these authors, the diagnostic instrument is freely available to researchers and clinicians.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (28 March 2010)
Page navigation anchor for Brief, but can we make it fit?
Brief, but can we make it fit?
Daniel C. Vinson, Columbia, MO USA
A 27-question screening form is shorter than many options for screening for the many problems the M-3 includes. But is it short enough? To be maximally useful, screening needs to be performed routinely on every patient who might have the one of the conditions. Asking every patient, or at least most, to complete a 27-item checklist will require dedication to these issues, potentially neglecting the multitude of other recomme...
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A 27-question screening form is shorter than many options for screening for the many problems the M-3 includes. But is it short enough? To be maximally useful, screening needs to be performed routinely on every patient who might have the one of the conditions. Asking every patient, or at least most, to complete a 27-item checklist will require dedication to these issues, potentially neglecting the multitude of other recommended screening services. (See Yarnall et al. Primary care: is there enough time for prevention? Am J Public Health 2003; 93:635-641.) There is much more we could do than we currently can do, and fidelity to those things probably will accomplish more for our patients than innovation. (See Woolf et al. The break-even point: When medical advances are less important than improving the fidelity with which they are delivered. Ann Fam Med 2005; 3:545-552.)
The question therefore remains: How can we do better?
1. Building on the work by Gaynes and his colleagues, we need even shorter, simpler screening approaches. (See for example Goodyear-Smith et al. Case-finding of lifestyle and mental health problems in primary care: Validation of the 'CHAT' tool. Brit J General Practice 2008; 58: 26-31.)
2. We need to integrate screening into our electronic medical records, giving patients access to their own record, inviting them to complete screening online and in advance of an office visit.
3. We need to develop computer systems that can "intelligently" respond to those online screenings, providing education and an invitation to follow up the issues raised with the family physician.
4. We need implementation research. What are the most effective, efficient, comfortable, and engaging ways to integrate the wide range of screening services into routine care.
Thanks, Dan Vinson
Competing interests: None declared
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Competing Interests: None declared.